This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Oxygen Delivery Systems & SuppliesPrograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program,OH MyCare, and OH Just4Me TM Po l i c yEffective January 1, 2014, CareSource provides coverage for the rental of oxygen delivery systems and supplies when a claim meets the criteria outlined in this policy. De f i n i t i o n sCurrent Procedural Terminology ( CPT ) codes are numbers assigned to every task , medical procedure, and service a medical practiti oner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Healthcare Common Procedure Coding System (HCPCS ) is a set ofhealth care procedure codes based on the American Medical Association ‘sCurrent Procedural Terminology (CPT). HCPCS currently includes two levels of codes: Level I consists of the American Medical Association ‘s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, [2] and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I). (from www.wikipedia.org ) Medically necessary services are those health services that are necessary forthe diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization CareSource doe s not require prior authorization for medically necessary oxygen equipment and supplies for its members. ReimbursementCareSource will reimburse providers for the rental of oxygen supply systems and supplies for any member within the following parameters: This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 HCPCS CodeDescription LimitsK0738 Trans fill oxygen system Each : 1 per month per member E1390 Oxygen concentrator, single port E1391 Oxygen concentrator, dual port E1392 Portable oxygen concentrator, rental E0424 Stationary compressed oxygen system, rental E0431 Portable gaseous oxygen system, rental E0434 Portable liquid oxygen system, rental E0439 Stationary liquid oxygen system, rental BillingThe appropriate documentation must be attached to the claim form, or sent separately to CareSource for claims submitted electronically. Re l a t e d Po l i c ies & Re f e r e n c e sOhio Administrative Code 5160-10-03 , Medical supplies and the Medicaid supply list Ohio Administrative Code 5160-10-05 , Reimbursement for covered services. Ohio Administrative Code 5160-1-60 , Medicaid reimbursement. St a t e Ex c e p t i o n sNONE Do c u m e n t Re v i s i o n Hi s t o r y
Payment PolicySubject: Healthcare Acquired Conditions , Provider Preventable Conditions, and Conditions Present on Admission Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4MeTM Policy CareSource will , as applicable, deny claims for or reduce the reimbursement amounts for claims by providers that include healthcare acquired conditions or other provider-preventable conditions, or where one of the reported conditions was not present on admission for an inpatient stay, in accordance with CMS guidelines and protocols . Definitions Healthcare acquired condition (HAC ), means a condition occurring in any inpatient hospital setting which has a negative consequence for the member and which was not present in the member upon admission to that facility. (from Affordable Care Act of 2010, Section 2702) Provider preventable condition, means a condition occurring in any healthcare setting that is either a healthcare acquired condition or is another condition which has been found by the applicable state to be reasonably prevent able by the provider through the application of procedures supported by evidence-based medical guidelines, and which has a negative consequence for the member. These types of conditions include, but are not limited to, wrong surgical or other invasive procedures, surgical or other invasive procedures performed on the wrong body part, or surgical or other invasive procedures performed on the wrong patient.(from 42 CFR 447.26)Provider Reimbursement Guidelines Healthcare Acquired Conditions CareSource will not reimburse providers for healthcare acquired conditions in its members, in accordance with CMS guidelines. Provider Preventable Conditions CareSource will not reimburse providers for provider preventable conditions in its members. If CareSource can reasonably identify and isolate the portion of the claim which is directly related to the treatment of the provider preventable condition, then CareSource will reduce the reimbursement of the claim by that specific amount related to the provider preventable condition. CareSource will not, however, impose a reduction in reimbursement on any claim when a provider preventable condition is found in a CareSource member to have been present and in existence prior to the providers treatment of that member. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 o f 2 CareSource will take all necessary actions in order for any state to comply with and implement applicable federal and state laws, regulations, policy guidance and any state policies and procedures relating to the identification, reporting, and non-payment of claims with provider preventable conditions. CareSource requires providers to comply with all federal, state, and CareSource-issued reporting requirements around provider preventable conditions as a condition of claims reimbursement. Conditions Present on Admission Hospitals will not receive additional payment for inpatient claims in which one of the conditions reported on the claim was not present when the CareSource member was admitted to the facility. Any such claim will be paid as though the secondary diagnosis were not present. In accordance with CMS guidelines, CareSource requires fac ilities to promptly report present on admission information for both primary and secondary diagnoses when submitting claims NOTE : Regardless of how CareSource reimburses , reduces reimbursement for, or denies any claims under this policy, providers may not deny access to healthcare services to any CareSource member based on a healthcare acquired condition or provider preventable condition contracted by that member. Related Policies & References Deficit Reduction Act of 2005, Section 5001(c) , Hospital quality improvement. Affordable Care Act of 2010, Section 2702, Payment adjustment for healthcare acquired conditions. 42 USC 1396b-1, Payment adjustment for healthcare acquired conditions. 42 CFR 447.26, Prohibition on payment for provider-preventable conditions. 907 KAR 14:005, Healthcare acquired conditions and other provider preventable conditions. OH Department of Medicaid Hospital Handbook, HHTL 3352-13-05, Inpatient Hospital Reimbur sement on or after July 1, 2013. State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 o f 2
Payment PolicySubject: CPT Codes Not Covered in an Emergency Room Setting Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and Just4Me (all states)TM Policy CareSource will not reimburse claims for CPT Codes 93308, 93971, or 95992 when submitted with a Place of Service code 23 (Emergency Room-Hospital) , as set forth in this policy . This policy is not new and therefore has no specific effective date; rather, its purpose is to clarify any misunderstandings among our providers around these procedure codes. Definitions Current Procedural Terminology (CPT) codes are numbers assigned to every task , medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Healthcare Common Procedure Coding System ( HCPCS ) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT) . HCPCS currently includes two levels of codes: Level I consists of the American Medical Association’s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I) .( from www.wikipedia.org) Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice.( from OAC 5160-10-02) Place of Service Codes, ( POS ) means codes which are regularly published by the Centers for Medicare & Medicaid Services, and which are used on reimbursement claims submitted for professional services rendered by healthcare providers. These codes specifically indicate where a service or procedure was performed. (from www.cms.gov )This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2Provider Reimbursement Guidelines CPT Codes Addressed 93308: Follow-up or limited transthoracic echo (no Doppler or colorflow). 93971: Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. 95992 : Standard canalith repositioning procedures (e.g., Epley maneuver, Sermont maneuver), per day. ( Note: audiologists cannot bill Medicare for this procedure, as canalith repositioning procedures are not di agnostic tests) Prior Authorization No prior authorization from CareSource is required before providing these services to its members. Reimbursement It is CareSource policy to reimburse providers for the procedures defined by these CPT codes, unless these procedures are performed in the setting of an Emergency Room or freestanding emergency room (POS 23). When performed in an ER setting, the results of these procedures are generally referred to and read by the appropriate on-call specialist (a cardiologist, is one likely example) and the code is billed by that specialist. If the code is also billed by the emergency room unit, that means that CareSource is processing two separate claims for the same procedure, when only one procedure was rendered to the CareSource member. CareSource does not reimburse multiple providers for a single procedure, and on that basis, CareSource will deny claims for these procedures when performed in an ER setting . Related Policies & References State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will b e determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Abortion Po l i c yCareSource will cover abortions for eligible CareSource members under strict federal guidelines, which require that the life of the mother would be endangered if the fetus were carried to term, or if the mother was a victim of rape or incest. Abortions are not covered if use d for family planning purposes. De f i n i t i o n s42 C.F.R. 441.201, Title 42 – Public Health defines the standards under which abortion p rocedures can be performed for f ederally funded health care. A therapeutic abortion is the termination of a pregnancy where fetal hearttones are present at the time of the abortive procedure. The termination of a pregnancy may be induced medically (prostaglandin suppositories, etc.) or surgically (dilation and curettage, etc.). This includes the delivery of a non-viable (incapable of living outside the uterus) but live fetus, if labor was augmented by pitocin drip, laminaria supp ository, etc. (from ncdhhs.gov) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior AuthorizationPrior authorization is required for the administration of an abortion procedure to validate medical necessity per federal regulations. The consent form must be submitted with the request for authorization. ReimbursementReimbursement is available for abortions only when the abortion is required to be covered under federal law subject to limitations and restrictions set out in 42 CFR Subpart CSec.50.301, 5 0.302, 50.303, 50.304, 50.306, 42 CFR 441.200 Sec441.200, 441.201, 441.202, 441.203, 441.206, 441.207, 441.208, 405 . All appropriate documentation must be attached to the claim and to claims for directly related services before CareSource can reimburse for any claim . CareSource will reimburse for drugs or devices to prevent implantation of the fertilized ovum, and for medical procedures for the termination of an ectopic pregnancy. The requirements stated below do not apply to those abortions that are tr eatments for incomplete, missed, or septic abortions. Reimbursement for abortion services, other than those identified above, is restricted to the following circumstances when the appropriate certification is made: Instances in which the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is pe rformed; or This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will b e determined when the claim is received for processing. Page 2 of 2 Instances in which the pregnancy was the result of an act of rape and the patient, the patients legal guardian or the person who made the report to the law enforcement agency, certifies in writing that a report was filed, prior to the perform ance of the abortion, with a law enforcement agencyhaving the requisite jurisdiction, unless the patient was physically unable to comply with the reporting requirement and that fact is certified by the physician performing the abortion; or Instances in which the pregnancy was the result of an act of incest and the patient, the patients legal guardian or the person who made the report certifies in writing that a report was filed, prior to the performance of the abortion, with either a law enforcement age ncy having the requisite jurisdiction, or, in the case of a minor, with a county children services, unless the patient was physically unable to comply with the reporting requirement and that fact is certified by the physician performing the abortion. Certification Before reimbursement for an abortion can be made, the physician performing the abortion must certify that one of the three circumstances outline above has occurred. The certification must be made on the appropriate state-specific certificati on form . All certifications must contain the name and address of the patient. The certification form must be properly executed and submitted to CareSource , including appropriate signatures . Claims for payment will be denied if the required consent is not attached or if incomplete or inaccurate documentation is submitted. Reimbursement will not be made for associated services such as anesthesia, laboratory tests, or hospital services if the abortion service itself cannot be reimbursed. Re l a t e d Po l i c ies & Re f e r e n c e s42 C.F.R. [Code of Federal Regulations] 441, Subpart Eor Subpart FOAC Chapter 5160-17-01 Abortions 907 KAR 1:054. Primary care center and federally-qualified health center services KRS [Kentucky Revised Statutes] 205.010( 3), 205.510(5), and 212.275(3) National Coalition (NC) Division of Medical Assistance – Medicaid and Health Choice – Clinical Coverage Policy No.: 1E-2 – Therapeutic and Non-therapeutic Abortions (Revised Date: March 1, 2012) St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013 OAC Rule renumbered from 5101:3-17-01 , per Legislative Service Commission Guidelines.
Payment PolicySubject: Provider Issue Resolution Process Policy It is the CareSource policy to ensure that all providers of medical services to CS members are reimbursed timely for all properly submitted medical claims. CareSource has an appeal process for resolution of denied claims and disputes of payment amounts. Definitions Retrospective review is the evaluation of medical necessity and appropriate billing for services that have already been rendered. (from mibcn.com/glossary) Provider Reimbursement Guidelines Medical Claims Administration Providers have 180 days from the date of service or, in the case of an inpatient admission from date of discharge, to submit a medical claim. This timeline includes submitting corrected medical claims. Pr oviders may appeal a payment amount or payment denial any time within 365 days of the payment notification. Services not previously reviewed for medical necessity are categorized as retrospective reviews and are reviewed and determination is made by the Medical Management Department within 30 calendar days of receipt. Inquiries CareSource wants providers to receive the best service each time they contact CS and to ensure the proper internal CS teams are called on to do so. Providers should direct claims inquiries and appeals to the provider web portal at https://providerportal.caresource.com . This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 o f 3General provider inquiries can be directed to these sources outlined below: Category Source(s) Member Eligibility Check IVR Provider Portal: providerportal.caresource.com Coordination of Benefits Provider Portal: providerportal.caresource.com Prior Authorization Provider Portal: providerportal.caresource.com or 1-800-488-0134, please listen for the selection. Internal CareSource Resources Provider Relations is responsible for contracting and contract related needs such as PCP capacity changes, provider demographics changes, orientation for new providers to our network, and ongoing provider education. A Provider Relations Representative cannot expedite claims through processing. However, a Provider Relations Representative is are available to assist providers with root cause analysis, to monitor trend issues and to educate providers on new offerings and enhancements fro m CareSource. The Provider Service Center is trained and equipped to respond to claims and other non-contract related inquiries. The Provider Service Center serves as the main point of contact for all CS providers. the Provider Service Center documents all calls and inquiries. Call/Inquiry documentation is reported to CS management team who reviews for trends and other provider needs and responds accordingly. If you have a question about: Then:The status of a claim and it has been less than 45 days since submission. Use the Claims Inquiry function on the Provider Portal for the status on the processing of your claim. A claim that is in pended or P9 status. There is no action required on your part. This means the claim needs manual intervention and is being reviewed. A claim that has been pending or in P9 status for more than 60 days. Call the Provider Services Representative for the status on this claim. A claim that has been processed but the provider disagrees with how the claim processed, and the claim was correctly submitted. Submit a formal appeal within 365 days from the date of payment or denial. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 o f 3Related Policies & References CareSource Provider Manual State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 o f 3
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Post Stabilization Care Services Po l i c yCareSource will be responsible for medically-necessary post-stabilization care provided by any participating or non-participating emergency room for eligible members. Prior authorization is not required for any emergency department services or for services by a participating provider in an observation setting. De f i n i t i o n s Emergency medical condition ,” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medi cal attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. (from OAC 5101:3-26-01 (W, X)) “Post-stabilization care services are covered services related to an emergency medical condition that a treating physician views as medically necessary and that are provided to the patient after an emergency medical condition has been stabilized. Post Stabilization Care Services are rendered to maintain, or under certain circumstances to improve or resolve the members stabilized condition. (from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals .pdf) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s The purpose of this policy is to explain CareSource coverage for Post – Stabilization Care Services when provided in an emergency department. Prior Authorization Prior authorization is not required for coverage of Post-Stabilization Services when these services are provided in any emergency department or for services by a participating provider in an observation setting. To request prior authorization for observation services as a non-participating provider or to re quest authorization for an inpatient admission please call 1-800 – 488-0134. When calling, follow the prompt for Post Stabilization. During regular business hours, the call will be answered by the CareSource Medical Management Department. If calling after regular business hours, the call will be answered by the CareSource Nurse Triage Line. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 If there is mutual agreement about a non-participating facility providing observation services, the non-participating facility must sign a negotiated rate form to attest that they will accept Medicaid reimbursement. Refer to the CareSource Medical Managem ent Out of Network Referrals and Negotiations policy for additional information. Coverage Post-stabilization care services are covered services that are: Related to an emergency medical condition; Provided after a CareSource member is stabilized; and Provided to maintain the stabilized condition, or under certain circumstances, to improve or resolve the members condition. CareSources financial responsibility for post-stabilization care services ends when: A non-participating emergency room at the treating hospital assumes responsibility for the members care; A non-participating hospital assumes responsibility for the members care through transfer; A CareSource representative and the non-participating treating physician reach an agreement concer ning the members care; or The member is discharged. Re l a t e d Po l i c i e s & Re f e r e n c e sOAC Chapter 51 60-26-3, Managed Care Plan , Managed health care programs , Covered services. CMS Medicare Managed Care Manual – Chapter 4 – Benefits and Beneficiary Protections ; 20.5 Post-Stabilization Care Services CareSource Emergency Department Services Policy St a t e Ex c e p t i o n sNONE Do c u m e n t Hi s t o r y10/31/2013 OAC Rule renumbered from 5101:3-26-3, per Legislative ServiceCommission Guidelines.
REIMBURSEMENT POLICY STATEMENT KENTUCKY MEDICAID Policy Name Policy Number Effective Date Colorectal Cancer Screening PY-0403 10/23/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 3 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 5 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 5 H. REFERENCES ………………………………………………………………………………………… 5 Colorectal Cancer Screening KENTUCKY MEDICAID PY-0403 Effective: 10/23/2019 2 A. SUBJECT Colorectal Cancer Screening B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to Humana CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Humana CareSource will reimburse participating providers for medically necessary and preventive colorectal screening examinations and laboratory tests for asymptomatic members as required by state requirements through criteria based on guidelines from the American Cancer Society (ACS). C. DEFINITIONS Average risk: Per American Cancer Society Guidelines, members who are at average risk for colorectal cancer do NOT have: o Personal history of colorectal cancer or certain types of polyps o Family history of colorectal cancer o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease) o A confirmed or suspected hereditary colorectal cancer syndrome (i.e. familial adenomatous polyposis or Lynch syndrome) o Personal history of getting radiation to abdomen or pelvic area to treat prior cancer Increased or high risk: Per American Cancer Society Guidelines, members who are at increased or high risk of colorectal cancer include: o Strong family history of colorectal cancer or certain types of polyps o Personal history of colorectal cancer or certain types of polyps o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease) o A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-polyposis colon cancer or HNPCC) o Personal history of radiation to the abdomen (belly) or pelvic area to treat a prior cancer Colorectal Cancer Screening KENTUCKY MEDICAID PY-0403 Effective: 10/23/2019 3 D. POLICY I. This policy addresses the following screening examinations and laboratory test options for colorectal cancer screening for asymptomatic members: A. Stool based tests for colorectal cancer screening include 1. Highly sensitive fecal immunochemical test 2. Highly sensitive guiac-based fecal occult blood test 3. Multi-targeted tool DNA test B. Visual examinations for colorectal cancer screening include 1. Colonoscopy 2. CT colonography 3. Flexible sigmoidoscopy II. Humana CareSource does not require prior authorization for members with average risk for colorectal cancer who are 45 years of age and older. III. Humana CareSource DOES require prior authorization for members who are at high risk and are less than 45 years of age. IV. Humana CareSource will use MCG for medical necessity review. V. Humana CareSource reimburses for colorectal cancer screening examinations and laboratory tests with the frequency noted in the most current American Cancer Society guidelines for people with average risk for colorectal cancer. VI. A follow-up colonoscopy is reimbursed as part of the screening process when a noncolonoscopy test is positive. VII. When billing for screening examinations and laboratory tests colorectal services, providers should use the appropriate CPT/HCPCS codes and modifiers, if applicable. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting state Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the state Medicaid fee schedules. Code Description 44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 44389 Colonoscopy through stoma; with biopsy, single or multiple 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) Colorectal Cancer Screening KENTUCKY MEDICAID PY-0403 Effective: 10/23/2019 4 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 74263 Computed tomographic (CT) colonography, screening, including image postprocessing 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy G0104 Colorectal cancer screening; flexible sigmoidoscopy G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Modifiers Description PT Colorectal cancer screening test; converted to diagnostic test or other procedure 33 Preventive Services ICD-10 Description Z12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecified Z12.11 Encounter for screening for malignant neoplasm of colon Z12.12 Encounter for screening for malignant neoplasm of rectum Colorectal Cancer Screening KENTUCKY MEDICAID PY-0403 Effective: 10/23/2019 5 F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 2/1/2014 Date Revised Date Effective 10/23/2019 New title was colonoscopies; updated based on ACS guidelines H. REFERENCES 1. American Cancer Society (2018). Colorectal Cancer Screening Guidelines. Retrieved on 12/21/2018 from https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/colorectal-cancer-screening-guidelines.html a/nd https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html 2. American Medical Association (2018). Care Guidelines for Evidence-Based Medicine. MCG Health. Retrieved on 12/21/2018 from www.mcg.com/care-guidelines/care-guidelines/. 3. Kentucky Administration Regulation 304.17A-257 Coverage under health benefit plan for colorectal cancer examinations and laboratory tests. Retrieved on 12/ 21/2018 from 304.17A-257 Coverage under health benefit plan for colorectal cancer examinations and laboratory tests. 4. Wolf, A., Fontham, E., Church, T., Flowers, C., .Smith, Robert. (2018). Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. Retrieved on 12/21/2018 from https://onlinelibrary.wiley.com/doi/full/10.3322/caac.21457. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT KENTUCKY MEDICAID Policy Name Policy Number Date Effective Medical Drug Reimbursement Rates PY-0797 05/19/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimburse ment Polic y Sta teme nt : Reimburse ment Policies prepared b y CSMG Co. a nd its a ffiliates (inc luding CareSource) a re inte nded to pro vide a genera l refere nce regardi ng billi ng, coding a nd doc ume nta tion g uidelines. Coding methodolog y, regulator y requireme nts , ind us try-s tanda rd claims editing logic , bene fits design a nd other fac tors are co nsidered in de velopi ng Reimburse ment Po licies. In addition to this Polic y, Reimburseme nt of services is subjec t to me mber be nefits a nd eligibility o n the da te of service, medical necessity, ad here nce to pla n polic ies a nd procedures, claims editing logic, pro vider co ntrac tual agreeme nt, a nd app licable referral, authori zatio n, notification and utili zatio n manageme nt g uidelines . Medically necessary services i nclude, b ut are no t limited to , those health care services o r s upplies that are proper a nd necessary fo r the diagnosis or treatme nt o f disease, illness, or i njury a nd witho ut which the patie nt can be e xpected to s uffer pro longed , i ncreased o r ne w morbidity, impairme nt o f func tion, d ys functio n of a body orga n or par t, or sig nificant pain a nd discomfort. These services meet the sta ndards of good medical practice i n the local area, are the lo west cost alternati ve, and are not pro vided mainly for the co nvenie nce o f the me mber o r p rovider. Medically necessary se rvices also i nclude those services defi ned in any federa l or state co verage ma ndate , Evidence o f Cove rage docume nts , Medical Policy State ments, Pro vider Ma nuals , Me mber Ha ndbooks, a nd/or other policies and proced ures. This Policy does no t e ns ure a n a utho rizati o n or Reimb urseme nt of se rvices. Please refer to the pla n co ntract (often referred to as the Evidence o f Coverage) for the service(s) re fere nced herein. If there is a conflict be twee n this Polic y a nd the pla n co ntract ( i.e. , Evidence of Co verage), the n t he pla n co ntract ( i.e . , Evidence of Coverage) will be the contro lli ng document used to make the determina tion. CSMG Co. a nd its a ffiliates ma y use reasonab le discretio n in interpre ting a nd applying this Polic y to services pro vided in a particular case a nd ma y modify this Polic y a t a ny time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Backgro und ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………. 2 G. Review/Revisio n History ………………………….. ………………………….. ………………………….. ………. 2 H. References ………………………….. ………………………….. ………………………….. ………………………… 3 Medical Drug Reimburse ment Rates KENT UCKY MEDICAID PY-0797 Effective Date: 05/19/2019 2 A. Subject Medical Drug Reimbursement Rates B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when t he claim is received for processing. Healt h care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/ HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Average Wholesale Price (AWP) – is the manufact urer’s list price of the drug when sold to the wholesaler. Average Sales Price (ASP) a rate that is calculated by the manufact ure on a quarterly basis and submitted to Medicare. Medicare then places these rates in a file and uploads to the Medicare Part BDrug Average Sales Price Dr ug Pricing Files tab on cms.gov. D. Policy I. This is a reimbursement policy that outlines reimbursement rates for drugs that are billed and administered in the following places of service under the members medical benefit only when drug reimbursement rates are not specifically called out in t he provider contract or the drug code is not listed on the Kent ucky Medicaid Fee Schedule: A. Place of Service 11 Office 1. Medicares ASP (Average Sales Price) plus 6% B. Place of Service 12 Home 1. Manufactures AWP (Average Wholesale Price) minus 15% C. Place of Service 22 On Campus-O utpatient Hospital 1. Manufactures AWP (Average Wholesale Price) minus 15% D. All dr ug codes billed on a UB-04 claim form 1. Manufactures AWP (Average Wholesale Price) minus 15% E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Kent ucky Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Kentucky Medicaid fee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT ION Medical Drug Reimburse ment Rates KENT UCKY MEDICAID PY-0797 Effective Date: 05/19/2019 3 Date Issued 0 4/15/2019 Date Revised Date Effective 05/19/2019 H. References The Re im burseme nt Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r e cei v e d due c on si d e ra t i o n a s d e f i n e d i n the Re im burseme nt Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. KY-HUCP0-1250 KDMS Approval: 04/15/2019
REIMBURSEMENT POLICY STATEMENT KENTUCKY MEDICAID Policy Name Policy Number Date Effective Drug Testing PY-0087 7/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable ref erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT …………………………………………………………………. 1 TABLE OF CONTENTS ……………………………………………………………………………………………….. 1 A. SUBJECT …………………………………………………………………………………………………………… 2 B. BACKGROUND ………………………………………………………………………………………………….. 2 C. DEFINITIONS …………………………………………………………………………………………………….. 2 D. POLIC Y ………………………………………………………………………………………………………………. 3 E. COND ITIONS OF COVERAGE ………………………………………………………………………….. 5 F. RELATED POL IC IES/RULES …………………………………………………………………………….. 7 G. REVIEW /REV IS ION HIS TORY…………………………………………………………………………… 8 H. REFERENCES …………………………………………………………………………………………………… 8 Drug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 2 A. Subject Drug Te sting B. Background Reimbursement policies are designed to assist you when submitting claims to Humana CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to Humana CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualitative and definitive/quantitative. C. Definitions Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as presumptive testing. Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as confirmatory or definitive testing. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) – this benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test a laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating Participating means in-network and contracted with Humana CareSource. Non-participating, means out-of-network, not contracted with Humana CareSource. Residential services for substance use Kentucky regulation defines residential as a 24 hour per day unit that is a live-in facility offering planned structure care to treat members with addition or co-occurring mental health and substance use disorders. Drug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 3 Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the Humana CareSource Drug Testing Medical Policy, MM-0064. Please refer to this policy for in-depth information on medical necessity for drug testing, documentation requirements, and Humana CareSource monitoring and review of drug testing claims. D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. Humana CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. Humana CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. PA is required for UDT for members 7 years and older when a definitive/quantitative test G0482 (15-21 drug classes) or G0483 (22 plus drug classes) is ordered. These drug tests are rarely indicated for routine urine drug testing. 2. PA is required for any non-participating provider with Humana CareSource for non-emergency room setting. 3. PA is required for any non-participating lab/facility with Humana CareSource for non-emergency room setting. 4. PA is not required in an emergency room setting. UDT utilization will be monitored by Humana CareSource. 5. PA is not required for members age 6 and younger. B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the ordering physician must obtain the prior authorization. III. Quantity Limitations A. Humana CareSource will reimburse up to 25 UDT in a calendar year for each member. 1. Each CPT code is counted as one test toward the 25 total drug tests in a calendar year. 2. UDT G0482 and G0483 (requiring a PA as noted above) will also count toward the 25 total UDT in a calendar year. B. There are no quantity limits for members age 6 and younger. Drug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 4 IV. Laboratory A. Only Humana CareSource identified laboratories can bill for definitive/quantitative UDT. B. Participating laboratories performing drug testing services must bill Humana CareSource directly. Humana CareSource does not allow pass-through billing of se rv ice s. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to Humana CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care service for children under age 21. VI. Non-Urine Testing A. Humana CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples performed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VII. Urine Testing A. If the provider suspects that the urine is adulterated, the provider may choose to evaluate specimen validity using validity tests. Specimen validity testing is considered to be a quality control issue and is included in the CPT code payment. Additional codes for specimen validity testing should not be separately billed to Humana CareSource. Specimen validity tests such as creatinine, specific gravity, or nitrates are not billable to and will not be reimbursed by Humana CareSource when submitted simultaneously with a drug testing CPT code. B. Failure to document customized tests with medical necessity information for each individual member and for each of the drug tests ordered will result in the denial of the claim for reimbursement, audit, and/or overpayment requests, and any other program means for enforcing this policy. C. Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse. D. Orders for custom profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or to conduct additional testing as needed, are NOT billable to and will not be reimbursed by Humana CareSource E. Testing on a routine basis is neither random nor individualized. Routine or reflex testing is NOT billable to and will not be reimbursed by Humana CareSource. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random. F. Humana CareSource does not provide coverage for drug testing as a requirement to stay in a residential facility or sober center. VIII. Definitive/Quantitative and Duplicative Testing A. Routine multi-drug definitive/quantitative testing is not billable and will not be reimbursed by Humana CareSource. B. Definitive/quantitative testing must be individualized for the member and Drug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 5 medically necessary. Routine definitive/quantitative drug tests with negative presumptive/qualitative results are not covered by Humana CareSource. C. Definitive/quantitative testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: a. Presumptive/qualitative testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication OR b. Presumptive/qualitative testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member disputes the presumptive/qualitative testing results OR c. Presumptive/qualitative testing was positive for illegal drug AND the member disputes the presumptive/qualitative testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive/qualitative testing D. Routine nonspecific or wholesale orders for presumptive/qualitative drug testing or for definitive/quantitative drugs of abuse testing are not billable. IX. Other Non-Billable Drug Testing A. Standing orders set up between a provider and laboratory which are prewritten and/or result in the same drugs and drug classes to be tested on a routine, repeat basis, are not billable to and will not be reimbursed by Humana CareSource. B. Drug testing is not billable and will not be reimbursed by Humana CareSource if required by a third party such as: 1. Medico-legal purposes (e.g., court-ordered drug test) or 2. For employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment). 3. As a condition of: a. Participation in school or community athletic activities or programs b. Participation in school or community extra circular activities or programs 4. As a component of a routine physical/medical examination e.g. enrollment in school, enrollment in the military, etc., EXCEPT for once yearly screening in EPSDT programs. 5. As a component of medical examination for any other administrative purposes not listed above (e.g., for purposes of marriage licensure, insurance eligibility, etc.). 6. As a program requirement to live in residential facility or sober center. NOT E: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGE Re imburse me nt is de pe nde nt on, but not limite d to, submitting Ke ntucky Me dica id a pprove d HCPCS a nd CPT code s a long w ith a ppropria te modifie rs a nd ICD-10 code s. Ple a se re fe r to the Ke ntucky Me dica id fe e sche dule.Drug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 6 The follow ing list(s) of code s is provide d a s a re fe re nce . This list ma y not be a ll inclusive a nd is subje ct to upda te s. Ple a se re fe r to the a bove re fe re nce d source for the most curre nt coding informa tion. Code s Qua lita tive /Pre sumptive Te sts-De scription 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Code s Qua ntita tive /Confirma tory Te sts-De sc ription G0480 Drug Test definitive/Quantitati ve 1-7 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug Test definitive/Quantitati ve 8-14 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0482 Drug testing definitive/Quantitati ve 15-21 classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative,Drug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 7 all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed G0483 Drug testing definitive/Quantitati ve 22+ classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed G0659 Drug testing definitive/Quantitati ve non-specified number of drug classes Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes F. RELATED POLICIES/RULES Humana CareSource Drug Testing Medical Policy (MM-0064) G. REVIEW/REVISION HISTORY DAT EACT ION Da te Issue d 01/01/2014 New Policy. Da te Re vise d 10/01/2017 11/2018 Updated limits, prior authorization requirements, and covered/defu nct codes. 1/2019 Updated limits, prior authorization requirements, codes, and items not configurable 4/1/2019 Updated quantity limits and PA requirements and identified laboratories Da te Effe ctive 7/1/2019 H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science. Retrieved on 12/11/2018 from https://blumsrewarddeficiencysyndrome.com/ets/articles/ v1 n1/jr dsas-025-adi-jaffe.p df 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 fromDrug Tes ting KENTUCKY MEDICAID PY-0087 Effective Date: 7/1/2019 8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC47 106 47/p df/ 114 69 _20 15 _Article_ 956 9.pdf 3. American Society of Addiction Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https://www.asam.org/docs/default-source/public-policy-statements/1drug-testing– -clinical-10-10.pdf?sfvrsn=1 b1 1ac97 _0 #sea rch=”uri ne drug testing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine. Retrieved on 12/13/2018 from https://journals.lww.com/journaladdictionme dicine/Fulltext/20 17/0 60 00/App ro pri ate_ Use_of_Drug_Testin g_in _Cli nical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMW R. Recommendations and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr 65 01e 1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https://www.ecfr.gov/cgi-bin/retrieveECFR?g p=3&SID=7 282 61 6ac5 742 25 f7 95 d58 49 93 5efc45&ty=HTM L&h=L&n=pt42.1.8&r=PART#se42.1.8_1 2 7. Kentucky Administrative Regulation, 907 KAR 15:020. Coverage provisions and requirements regarding services provided by behavioral health services organizations. Retrieved on 12/11/2018 from http://www.lrc.ky.gov/kar/907/015/02 0.pd f 8. Kentucky Administrative Regulation 201 KAR 9:270. Professional standards for prescribing or dispensing Buprenorphine-Mo no-Pr oduct or Buprenorphine-Com bine d-with-Naloxone. Retrieved on 12/11/2018 from http://www.lrc.ky.gov/kar/201/009/270.p d f 9. Kentucky Board of Licensure. Considerations for Urine Drug Screening. Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Pa ges/de fault.aspx 10. Medicaid. Early and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https://www.medicaid.gov/medicaid/b en efits/epsdt/ind ex.html 11. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal. Retrieved 12/13/2018 from http://www.painphysicianjournal.com/curr ent/p df?a rticle=MTcxMA%3 D%3D&j ou rnal= 68 12. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https://www.va.gov/PAINMANA GEMENT/ docs/OSI_ 1_ Tookit_Pr o vi de r_A D_Ed ucation al_Guide_7_17.pdf 13. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Documents/Resources%20SAW ashingt on%2 0State%20 Inter age ncy%20G uideli ne%20on%20Opioid%20Dosing%2 0for% 20 Chr onic%2 0Non-Cancer%20Pain%20Uri ne%2 0Dru g%20 Testing%2 0G uida nce.pd f The Reim burs ement Policy Statement detailed above has received due consideration as defined in the Reim bursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT KENTUCKY MEDICAID Policy Name Policy Number Date Effective Avastin for use in Ophthalmology Billing Guideline PY-0732 05/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Avastin for use in Ophthalmology Billing Guideline KENTUCKY MEDICAID PY-0732 Effective Date: 05/01/2019 2 A. Subject Avastin for use in Ophthalmology Billing Guideline B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Avastin is a drug used in the treatment of wet age-related macular degeneration, diabetic eye disease and other problems of the retina. Avastin is injected into the eye and helps to slow down disease related vision loss. The use of Avastin to treat eye disease is considered off-label, which is allowed by the FDA when doctors are well informed regarding the drug and there are studies that prove its an effective treatment option. There is no cure for macular degeneration, treatment is aimed at slowing down the progression of the disease and preventing vision loss. C. Definitions Macular Degeneration a progressive vision impairment resulting from deterioration of the central part of the retina, known as macula. D. Policy I. CareSource does not require a Prior Authorization for the use of Avastin in Ophthalmology, when billed with the following codes: A. J3490 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. B. J3590 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. E. Conditions of Coverage HCPCS J3490, J3590 NDC 50242-0061-01 or 50242-0060-01 F. Related Policies/Rules N/A Avastin for use in Ophthalmology Billing Guideline KENTUCKY MEDICAID PY-0732 Effective Date: 05/01/2019 3 G. Review/Revision History DATE ACTION Date Issued 05/01/2019 New policy Date Revised Date Effective 05/01/2019 H. References 1. Boyd, K. (2018, May 22). What Is Avastin? Retrieved October 29, 2018, from https://www.aao.org/eye-health/drugs/avastin 2. “Off-Label” and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices-Information Sheet. (2018, July 12). Retrieved October 29, 2018, from https://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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